Express Application and Registration Form for Non-Matriculated Students 
Please Print 

Name:_______________________________________________________ Social Security Number:____________________________ 
Address:___________________________________________City___________________________State________Zip______________ 
Home Tel. # (____)__________________ Cell. Tel. # (____)_______________ E-mail: ______________________@____________ 
Date of Birth: ____/_____/____ Employer:_________________________________________________________________ 

____________________________________________________________ 

Semester Registering For: ___Fall ___Spring ___Summer ___Intersession 20_________ 
Campus Preferred ____Central Islip ____Manhattan ____Old Westbury ____Other _______________ 
Level of study for which you are registering: ____Undergraduate ____Graduate ____Professional 
Program of Study or Major Desired:

Have you previously applied to NYIT? ___ Yes ___ No 
If Yes -- To which Program of study? ___________________________________________________ 
-- Did you complete the program? ___ Yes ___ No -- Last semester attended? ____________________ 

I would like to register for the following course(s) 

Course/Reference # Course Title Credits / Units Course/Reference # Course Title Credits / Units 

Course/Reference # Course Title Credits / Units 

Under Title VI of the Civil Rights Act of 1964 the following information is required for the compliance report for institutions of higher education and is 
not used for admission purposes. 

(Check one) 
 American Indian or Alaskan Native  Black (Non Hispanic)  Hispanic 
 Asian / Pacific Islander  White (Non Hispanic)  Other  Do not wish to respond 

NYIT is an equal opportunity institution. Students are admitted without regard to race, religion, sex, age, national origin or handicap in compliance with the Executive order 
11246. Revised Order #4 and Section 504. 

I understand that by authorizing a registration, and or dropping or withdrawing from the courses that I have registered for during this semester, I agree to be charged in 
accordance with the published schedule of charges set forth in the college catalog with respect to payment of tuition, fees, refunds, the dropping and adding courses and the 
withdrawal policy procedures that are also available online at www.nyit.edu. I agree to be bound by this registration form and abide by the rules and regulations published 
in the current catalog. I agree to pay my debt to NYIT for any amounts due for tuition and fees and other charges. In the event that all charges are not paid when due, I 
agree to pay NYIT all of the costs associated with the collection of my delinquent account, which includes the payment to NYIT of the principal sums due, plus all costs, 
which may also include, but are not limited to collection agency fees constituting 33% of the principal balance due if NYIT engages a collection agency to secure payment, 
or legal fees constituting 50% of the principal balance due, if NYIT engages legal counsel to secure payment, plus any and all interest on the outstanding balance at the 
maximum legal rate allowed by law, and any and all other costs that will be associated with the collection of the delinquent amounts. All collection matters shall be governed 
by New York law; the courts of New York shall have exclusive jurisdiction in these matters. 

Students Signature 
Date 

PLEASE NOTE: ENROLLMENT ON THIS EXPRESS APPLICATION DOES NOT GRANT OR IMPLY ADMISSION TO A DEGREE PROGRAM AT NYIT 
THIS APPLICATION MAY NOT BE USED BY INTERNATIONAL STUDENTS SEEKING A STUDENT VISA 

 FOR OFFICIAL USE ONLY Indicate Student Type: 

APPROVED BY 

Faculty Advisor Date 
Admissions Office Date 


COMMENTS:__________________________________________________________________________________________________ 



